Aviation safety investigations & reports

Aircraft loading event - Airbus A330-202, VH-EBB, Sydney Airport NSW, 4 July 2009

Investigation number:
AO-2009-034
Status: Completed
Investigation completed

Summary

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On 4 July 2009, an Airbus A330-202, registered VH-EBB, was being operated on a scheduled passenger/freight flight from Sydney, New South Wales to Denpasar, Indonesia via Melbourne, Victoria. During loading of the aircraft at Sydney International Airport, a unit load device (ULD) was loaded onto the aircraft without the proper authorisation. Prior to the aircraft taxying for departure, loading personnel realised that the ULD had been mistakenly loaded. However, there was confusion in the communication of that information to the flight crew and they operated the flight to Melbourne without knowledge of the mis-loading.

The investigation found that the pilot in command rejected the loading of the ULD before it was loaded in the forward cargo hold, but the status of that ULD was not clearly communicated to the ground handling team and it was returned to the outgoing freight holding area of the departure bay. Contrary to the aircraft operator's procedures, the ULD was subsequently loaded into the aircraft's aft cargo hold, in the absence of a leading hand and without reference on the loading instruction report or the authorisation of the pilot in command. Contributing to the occurrence was a lack of procedure or guidance for the segregation of freight that had been rejected during loading.

The investigation identified a number of factors that did not contribute to the incident, but increased operational risk. Those factors related to the performance of the leading hand role, load-checking and procedures for communicating with flight crew after pushback.

The aircraft operator initiated proactive safety action to improve the training and supervision of loading staff, including guidelines for all staff involved with the training and support of new ports or ground handling agents. The operator also implemented procedures to enable ground handling agents to make emergency contact with the aircraft crew after pushback and incorporated those procedures in the relevant manuals.

Download Final Report
[Download  PDF: 2.73MB]
 
 
Alternate: [Download  DOC: 1.55MB]
 

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Safety Issues

Go to AO-2009-034-SI-01 - Go to AO-2009-034-SI-02 -

Quarantine procedures

There was no procedure or guidance for the segregation of freight that was rejected during loading.
Safety issue details
Issue number: AO-2009-034-SI-01

Ground handling emergency communication procedures

The aircraft operator did not provide procedures that allowed ground handling personnel to communicate effectively with the flight crew in the event of an urgent operational matter occurring after pushback.
Safety issue details
Issue number: AO-2009-034-SI-02
Status: Adequately addressed
General details
Date: 05 July 2009   Investigation status: Completed  
Time: 1515 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Sydney Airport    
State: New South Wales   Occurrence type: Loading related  
Release date: 19 May 2011   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus Industrie  
Aircraft model A330  
Aircraft registration VH-EBB  
Serial number 522  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Melbourne, Vic.  
Last update 14 November 2018